Measuring RTW outcomes in Workers’ Compensation: Part 2 – Jurisdictional Approaches

In Part 1, I highlighted three different approaches to measuring return-to-work outcomes:

1.     Standardized calculation based on standardized claims payment data at specific milestone submitted by jurisdictions (AWCBC approach),

2.     Retrospective survey of workers by central researcher group using a stratified sample from each jurisdiction withing strict time frames (Safework Australia),

3.     Retrospective interview approach normalized for each participating jurisdiction (WCRI)

 

Each approach provides insights for stakeholders and policy makers. Comparability and consistency among participating jurisdictions are often primary objectives. 

 

Individual jurisdictions have different objectives in measuring their RTW outcomes, each tuned to the features, priorities, and demands of their jurisdiction. 

 

With that in mind, here are four examples of jurisdictional RTW outcome measures.

 

Texas: 2023 Return to Work

 

The Texas Department of Insurance (TDI), Division of Workers’ Compensation, Workers’ Compensation Research and Evaluation Group (WCResearch) analyzed RTW outcomes for claims between 2007 and 2020 in this report. The report focuses on initial and sustained RTW (defined as a return to work and staying at work for three calendar quarters (9 months) following injury).

 

I asked WCResearch at TDI to expand on the study methodology:

 

The return-to-work report uses data on tens of thousands of employees who received Temporary Income Benefits (TIBs) after a work-related injury, examining wage records from the Texas Workforce Commission to determine when these individuals began earning wages again. The report assesses whether this return was classified as initial, referring to the first time an employee returns to work after the injury, or sustained, defined as maintaining employment for three consecutive quarters. These findings are linked to demographic details such as age, industry, employer size, and benefit type allowing for further statistical analysis. The methodology also includes an analysis of average wages before and after the injury, along with the average number of days employees spent away from work.

 

The results over the study period include the following:

 

92% of employees were back at work within one year.

 

69% of workers back at work within six months stayed at work and achieved pre-injury earnings within two years.

 

Days away from work averaged 43 (median 29).

 

For 2020 injuries, the initial RTW rate at six months post injury was 83%, a bit higher than the average 80% for the 2007-2020 study period. The sustained RTW rate was 69%, higher than the average 63% for the study period.

 

The “sustained” RTW outcome in this report is striking.  The three quarters (9 months) of earnings post RTW is a significant threshold and the objective sources for this data provide a rigour not found in many studies that rely on interview responses.

One challenge with this study approach is the lag necessary for a year’s cohort of claims to fully develop (close) to their ultimate duration. While that is happening, changes to law, policy, practice, and economic conditions may impact current RTW results.

 

Victoria Australia: WorkSafe Victoria RTW

 

WorkSafe Victoria has made return to work a “headline” Key Performance Indicator (KPI) in their Corporate Plan 2023-2024 and Strategy 2021-2024. (https://www.worksafe.vic.gov.au/resources/corporate-plan).  “At a headline level, we measure safe and sustainable return to work outcomes for injured workers with physical and mental injuries at 16 weeks, 26 weeks, 52 weeks and 104 weeks post claim lodgment. A return to work is defined as one that has been sustained for a three-week period.”

 

In Victoria, the claims management function is delivered by third party “agents” with WorkSafe Victoria oversight. Remuneration of agents includes a performance adjustment for meeting targets set for RTW outcomes at 26 weeks. Claims management software requires case managers code RTW status upon case closure and provide for case notes or other documentation confirming RTW details.

 

The following is my summary of WorkSafeVicotria’s methodology for the26 week (182 day):

1.     Calculation:
      Number of injured workers working at 182 days [divided by]                                                                                                     
     Population (paid claims in reporting period with > 10 days weekly compensation paid (including employer excess))

2.     RTW Status Assessment made 182 days post injury.

a.     Assessment of whether the worker has continued to remain at work for three weeks (21 days) following the return to work.

b.     Based on recorded fielded responses in systems (ACCtion, Fineos) and documentation of RTW (email, letter, Novus note, …).

3.     RTW Status Assessment and Validation at 21 days are subjected to random sample audit.

 

Note the exclusion of the 10 days of weekly compensation) in this calculation. Shorter duration absence in this range typically resolves with 100% RTW. Eliminating these from the calculation denominator and the numerator will tend to lower the overall RTW rate than if these cases were included.

 

WorkSafe Victoria’s data relies on the integrity of the information encoded in claims management systems about initial and continued employment at three weeks.  Audits of data entries to confirm the integrity of the coded information is a critical component of this measure.

 

A key feature WorkSafe Victoria’s RTW outcome reporting is the separate tracking of physical and mental injuries.  Mental injury cases tend to have longer recoveries. If a jurisdiction has a larger proportion of mental injury claims, a combined RTW measure will result in a lower percentage of RTW at 26 weeks.

 

For physical injuries, the result at 26 weeks is 73.60%, but for mental injuries, the return-to-work rate was 41.60%. This highlights a significant difference between mental injury cases and other injury types.

 

WorkSafeBC: Key Performance Indicator

 

WorkSafeBC is the operating name for the Workers’ Compensation Board of British Columbia. Its operational priorities include “Maximize overall recovery and post-injury earnings for injured workers”. A key performance indicator (KPI) to track progress against this priority objective is included in their Annual Report and Service Plan.

 

The KPI, “Improve return-to-work outcomes” carries the description: “The percentage of B.C. workers who return to work within six months (26 weeks) of their work-related injury.” The calculation method as stated in the 2024 Annual Report and 2025-2027 Service Plan (p. 34) is described as follows: 

 

“This KPI measures duration (by 26 weeks), whether the return to work is voluntary (the worker does not object), and whether it is safe and durable, with no subsequent inability to work for 30 days. To track the percentage, we compare the number of claims meeting these criteria with the total number of wage-loss claims open for more than 26 weeks.” [emphasis added].

 

Fielded case management data are used to determine status on closure. The absence of a claim re-opening indicating an inability to work infers durability.  There is no explicit confirmation of sustained RTW or return to full earnings.  

 

The KPI results reached a high of 81.3% in 2022 before falling to 78.5% in 2023 and rising again to 79.7% in 2024. The target going forward is to achieve 81.0% return to work by 26 weeks. (Note:  AWCBC records 85.00% (2022) and 83.62% (2023) under 25.5-Percentage of Wage-Loss Claims off Wage-Loss Benefits at 180 days (%)

 

There is no waiting period in British Columbia’s workers’ compensation system, so the results capture many very short duration claims.  These cases tend to have very high successful RTW outcomes.  Self-insurance is allowed in BC but not self-administration, so the results include for these deposit-class employers (governments, certain large employers) are also reflected in this measure.

 

South Australia: return-to-work milestones

 

When you rebrand your workers’ compensation authority “ReturnToWorkSA”, the messaging is clear. As you might expect, RTWSA has measures that reflect RTW status at various milestones such as 4, 12, 26, 52, and 78 weeks.

 

The data-rich report on ReturnToWorkSA Insurer Statistics FY2024 provides RTW outcomes for the 26-week milestone, similar to others noted in this part.  This time, there are three RTW status outcomes noted: “Not at work”, “Partially at work”, and “Fully at work”.  This reporting reflects a level of importance on “stay at work” outcomes within the system.  

 

The four-year time series provided for this milestone reflects a trend toward fewer workers not working and an increase in the number and proportion of workers fully RTW:

 

Not at work 5.7%,

Partially at work 3.5%,

Fully at work 90.9%. 

 

This is a population-based study reporting on 12,121 cases in the 2024 result.  According to RTWSA:

 “The milestone is measured from the workers first date of work incapacity, or injury date if the worker does not have work incapacity. Improvement has been achieved with a multifaceted program of work aimed at improving services to injured workers and employers.”

 

Note the subtlety of a worker suffering a work injury but not a work incapacity. The accepted claim covers the medical costs, but the worker may continue working on modified duties as part of a stay-at-work program, an approach actively promoted by RTWSA.

 

Summary Comment

 

Jurisdictional approaches to measuring RTW outcomes are often specifically crafted to address particular needs and priorities.  Where the national measures must find commonality among the jurisdictions, individual jurisdictions can allow the unique data systems and to provide greater depth.  Each approach starts with a purpose, and each design has its limitations.  In general, the results highlighted by the measure lag significantly behind changes in policy or initiatives to improve outcomes. 

 

Texas can focus on sustainable RTW outcomes, WorkSafe Victoria can differentiate results for mental and physical injury cases, and ReturnToWork South Australia can provide data on partial RTW and include successful stay at work outcomes that might be excluded from other designs.

 

Note the different approaches in determining sustainability.  In Part 1, we saw Safework Australia and WCRI ask workers directly about their work status as the time of interview. Their retrospective methodology builds in significant distance from initial RTW to assess sustainability of the RTW.  In Part 2, we see WorkSafeBC uses a case criterion “with no subsequent inability to work for 30 days” to exclude non-durable RTW outcomes from its measure, while WorkSafeVictoria uses an audited 21 day record (or direct/indirect inquiry) to assess whether the worker has continued to remain at work.

 

Again, there is no one “right way” to measure RTW outcomes.  Those jurisdictions willing to participate in studies, establish well defined measures, and post transparent results allow leadership, stakeholders, and policy makers assess performance and achieve better outcomes for injured workers and their families. 

In Part 3, we will look at RTW outcome trajectories. 

 

[This post was prepared as a resource for DMCCT- Evaluating DM Programs & Assessing RTW Processes, Pacific Coast University for Workplace Health Sciences]

 

Measuring RTW outcomes in Workers’ Compensation: Part 1 – National Approaches

 

A work-related injury or illness often results in time away from work. Workers’ compensation covers a part of the economic loss until (unless) a return to work is achieved.

 

A safe, early and durable return-to-work (RTW) outcome is the stated goal of many workers’ compensation programs, but few track or publicly report this important performance indicator. Those publicly reporting a return-to-work measure have various definitions, calculation methods and time frames. Comparing outcomes is further complicated by differences in industrial mix, demographic differences, and systemic features of the workers’ compensation schemes.

 

The good news is that most workers do return to work following a work-related injury or illness. How RTW outcomes are reported in the US, Canada and Australia provide insights, but interpretation is tricky. Each approach has its own purpose with advantages, disadvantages and limitations. Understanding what a RTW measure is describing requires an examination of the methodology, definitions, and timing applied in the data analysis.

 

RTW Scenarios and Measurement

 

The RTW trajectory for work injuries is not always linear and even. Following the injury, an accepted workers’ compensation wage-loss claim will pay temporary total disability (TTD) or temporary partial disability (TPD) entitlements until the worker’s condition ceases to be temporary, or employment earnings (actual or deemed) exceed temporary benefits payable.

 

Consider three simple RTW scenarios (there are many other scenarios):

 

1.     Injury-TTD-TPD (not working)- Full RTW at no loss of earnings at 20 weeks

2.     Injury-TTD-TPD with partial RTW reduced hours at 20 weeks -Full RTW at no loss of earnings at 30 weeks

3.     Injury-TTD-TPD with RTW full hours at temporarily reduced earnings (full-time light duties/alternate job) at 20 week benefits payable – RTW regular job at 30 weeks.

 

Each scenario results in a return-to-work outcome. In the first case, a full return to work at 20 weeks; in the second, there is a partial return to work at 20 weeks.  In the third case, there is a full-time RTW at 20 weeks in terms of hours, but a loss of earnings while the condition is still temporary.  How these cases will be considered depends on the RTW measurement design. 

 

Definitions of a case, RTW status and durability as well as the timing of the evaluation will yield different and not necessarily comparable measures of RTW outcomes.

 

Each measurement approach requires decisions about time frames and those choices have consequences. A choice to consider the population of accepted time-loss claims in a give calendar year will necessarily require the passage of time to allow for claims to develop.  An injury resulting in time loss beginning in December can’t be assessed against a 6 month RTW milestone until at least half a year following the injury. To measure the RTW outcomes of a cohort of claims from a given year may require waiting a year or two in order to determine some ultimate result, particularly if the measure is intended to reflect sustained RTW.

 

As noted,  a partial RTW (partial hours or reduced earnings while still TPD) may be included or excluded from consideration depending on the case definition and measurement approach. Counting TPD cases as successful RTW may overstate successful outcomes, but counting such cases as non-RTW ignores the value and success of stay-at-work and early RTW programs.

 

The durability of a RTW outcome may or may not be reflected in the RTW measures published. Durability depends on the definition. Three weeks, 30 days, or three calendar quarters of sustained employment after the last RTW are sometimes used for these purposes. If the RTW outcome measurement is based on current employment status, the timing of the measurement is also critical.

 

In survey or interview methods, a pair of survey or interview questions may be used: “Did you return to work?” and “Are you working now?” may be used to differentiate return to work outcomes and infer durability. The timing of these questions can also impact the result. If measured too soon after an RTW, the response may not reflect a sustained employment outcome; if measured long after the initial RTW, the result may reflect changes in other health or economic circumstances not related to the injury.

 

In designing a measure or interpreting a published RTW statistic (and its limitations), an understanding of the underlying choices and case decisions are essential.

 

National RTW Measures

 

The following examples illustrate different approaches to measuring RTW outcomes. One relies completely on administrative data; others ask workers directly about their RTW outcomes; and one blends claims data with interview responses

 

As you review the following examples, consider the purpose and limitations of each approach.  

 

While each example reports on a set of jurisdictions, direct comparison across studies is not possible.

 

Canada: The “Off Temporary Wage-loss Benefits” milestone approach

 

Administratively, the days or weeks of benefit paid are precisely and easily counted. Calculating an “off temporary wage-loss benefits rate” is often used as a proxy for a return-to-work rate.

 

The Association of Workers’ Compensation Boards of Canada (AWCBC) takes this approach. Each jurisdiction reports the percentage of time-loss claims “off wage-loss benefits” at specific milestones (30, 60, 90, 120, 180, and 360 day).

 

Let’s focus on Key Statistical Measure (KSM) 25.5, Percentage of Wage-Loss Claims off Wage-Loss Benefits at 180 days. The KSM is described as follows:

 

Intent of Measure

· To be a proxy of return to work. To measure how soon injured workers leave the [temporary] wage-loss compensation system permanently.

Definition

· Percentage of Total Lost Time Claims (KSM #2) that have received their last day of wage-loss benefits 180 days after the injury. The last day of wage-loss benefits is determined at December 31 of the year following the reference year.

Calculation

· Formula:P180 = C (D≤180) ÷ LTC, where:

•  D = The difference, in days, between the injury date and the last date for which an injured worker received any wage-loss benefits [emphasis added]. The last date of benefits is determined on December 31 of the year following the reference year. One-day medical visits or appointments can be excluded when determining the last date of benefits
• C(D≤180) = The number of claims for which the difference D is smaller or equal to 180 = Total Lost Time Claims (KSM #2). 
• Caveat 
• This is not a return to work measure although it can be seen as a proxy. Injured workers may stop receiving wage-loss benefits for a number of reasons other than returning to work. Also note that the measure makes no distinction with regards to what happens between the injury and the last day of wage-loss benefits. For instance, a worker that has temporarily returned to work before experiencing an aggravation is treated the same as if the wage-loss benefits never stopped. All aggravations or claim reopenings that occur after December 31 of the year following the reference year are not accounted for.

The data reported in this study come from the individual jurisdictions.  AWCBC advises, “The KSM 25s (25.1 to 25.6) are requested by AWCBC at a later date compared to all the other KSMs. When boards submit their KSM 25s we publish it after each CFO has approved their board's submission…we don't look at the case details…”. \

 

This approach relies heavily on individual jurisdictions’ coding and adherence to the AWCBC definitions. 

 

The 2022 Canadian result shows 88.21% of claims received their last time-loss disability payment within 180 days of injury. The results range from about 81% in Nova Scotia to over 94% in Manitoba.

 

Policy issues account for some of this variability. Nova Socia, for example, has a waiting period; short duration claims typically have 100% RTW rates after their very brief absences. The exclusion of these claims depresses the RTW rate at this milestone.

 

The administrative simplicity (using the full population of claims and objective payment data) makes this approach attractive, however, the results are not normalized across jurisdictions and do not directly measure RTW outcomes or account for successful partial returns to work. This retrospective approach necessitates a significant lag for the cohort of claims to develop.

 

Australia: The “RTW survey” approach

 

Asking the injured worker is a more direct method of determining RTW outcomes. When coupled with individual claims data, this approach opens the possibility of deeper analysis. On the other hand, the costs of contacting and interviewing are high. Unlike the previous administrative data/full population approach, this method requires a sampling strategy.

 

Australia’s National RTW Strategy tracks its progress through two headline measures: Returned to Work Rate (ever return to work) and the Current Return to Work Rate (currently working at time of survey). Sample size varies by jurisdiction and aggregates to about 5000 respondents. The stratified samples from each jurisdiction are selected from all cases with at least one day off work reported to the WC insurer (or authority) in a defined period (for example, February 1, 2019 to January 31, 2021). Interviewers (83) collect data by direct contact. This approach provides consistency or application across jurisdictions.  

 

The population includes both premium-paying and self-insured organizations. The sampling strategy included stratification techniques to strengthen representativeness of the sample. Results reflect weighting for factors including age and injury type (for example, psychological vs. others).

 

A full description of the most recent survey methodology is available at https://www.safeworkaustralia.gov.au/sites/default/files/2022-02/NRTW%20Methodological%20Report.pdf.

 

Nationally, the 2021 “ever” RTW rate was 91.6 %. The “current” RTW rate at time of surve was 81.4%. This broadly speaks to the issue of durability of a RTW outcome.

 

Note the variation in outcomes by jurisdiction. Seacare, reports a much lower RTW rates (76.3% ever, 62.3% current) than Comcare (95.6% ever, 87.6% current). Comcare covers employees of the Australian Government and certain large national companies that are self-insured under federal legislation, while Seacare specifically covers seafaring employees working on prescribed ships engaged in interstate or international trade or commerce within the Australian maritime industry. The jurisdictional injury and recovery profiles differ significantly and are reflected in the RTW rates.

 

Design makes the outcome measures meaningful, particularly for individual jurisdictions over time. There are challenges in follow up and the “lag” between current practice and measuring impacts of policy changes.

 

United States:  The “Outcome Interview and Data Analysis” approach

 

The US workers’ compensation landscape lacks a national RTW outcome report. The Workers’ Compensation Research Institute (WCRI) has conducted a series of studies “Comparing Outcomes for Workers” using the data from structured interviews and claims records for more than a dozen states. [Comparing Outcomes for Workers, 2019 Interviews. Bogdan Savych and Vennela Thumula. January 2020. WC-20-17 to WC-20-20]

 

The series focuses on:

Recovery of physical health and functioning

Return to work

Earnings recovery

Access to medical care

Satisfaction with medical care

 

In this study, the RTW outcome is defined as the corollary of the previous two studies. The percentage of claims “never” returning to work or failing to achieve a sustained one-month RTW are measured from stratified samples normalized for each jurisdiction in the study series.

 

This is a “members only” or “for purchase” series, however, a publicly posted WCRI.net video provides some results for the Connecticut version of the study.

 

The interviews took place three years after injury (2019).  Again , this approach provides consistency of application across jurisdictions. 

 

The results from the Connecticut version of the series displayed in the video show similar results across studied jurisdiction. Between 9% (Indiana) and 18% (Pennsylvania) “never returned to work” or never sustained a return to work for at least a month. This “never RTW” measure implies an “ever RTW” rate of between 82% and 93% using comparable data among the states included in the analysis.

 

The analysis shows the median state result as 10% never RTW [90% ever RTW] and 14% never RTW or not at least a month sustained [86% RTW or sustained at least 1 month].

 

The inclusion of claims data allows for further statistical analysis. For example, the median time between injury and the first sustained RTW was between 7 weeks (Florida) and 12 (Pennsylvania) weeks post injury.

 

The analysis provides policymakers and stakeholders comparative data to assess performance and improve systems. Through rigorous study design and application of advanced statistical methods, each participating jurisdiction receives a study allowing for outcomes to be directly compared relative to any state’s individual performance. Differences and similarities in outcomes can better inform policy decisions.

 

This approach also has its drawbacks. Rigorous design and interview protocols provide comparability, but there can be wide differences in when interviews take place among participating states. The number of states participating in the study is also limited. The design requires significant time for claims to develop then be surveyed and the results analyzed. Policy and economic impacts may not be reflected quickly or evenly across included states. 

 

(Full disclosure, I have acted as a technical reviewer for WCRI on this series).

 

Summary Comment

 

There is no “right way” to measure RTW outcomes. For national or group studies, the design often reflects compromises in setting objectives and achieving comparable data sets. Note the timeframes for RTW outcome studies necessarily lag changes in policy, practice and economic conditions. Rigorous definitions for cases and common application of techniques across jurisdictions take time and effort.

 

National or group results may be useful for policy decisions, however, the priorities of individual jurisdictions may differ significantly. In the next post we will look at several state/provincial approaches to measuring RTW outcomes.

 

In the next post, we will look at individual jurisdictions’ published RTW data. 

 

[This post was prepared as a resource for DMCCT- Evaluating DM Programs & Assessing RTW Processes, Pacific Coast University for Workplace Health Sciences]